STATEMENT OF SIDNEY COHEN, M.D., CLINICAL PROFESSOR OF PSYCHIATRY, UCLA MEDICAL SCHOOL, THE NEUROPSYCHIATRIC INSTITUTE, LOS ANGELES, CALIF.

Dr. COHEN. Mr. Chairman, members of the committee, I am grateful for the opportunity to present certain views on the problem of heroin usage among the Armed Forces in Southeast Asia.

I am a clinical professor of psychiatry at UCLA. Until a year ago I was Director of the Division of Narcotic Addiction and Drug Abuse at the National Institute of Mental Health.

I remain a consultant to that organization. I am a member of the VA Committee on Alcoholism and Drug Dependence, and also a member of the FDA Methadone Advisory Committee.

I do not represent any of these Federal agencies. Instead I come here as a student of the problems of drug abuse in the hope that I can contribute to your efforts to reverse a new and disturbing aspect of the heroin problem.

Every war has its enormous stresses, its turmoil, and its boredom. These have often driven combatants to the overuse of drink or drugs. For example, following our Civil War, morphinism was called the Soldiers Disease.

Morphine which had been recently extracted from opium, and the newly invented hypodermic syringe combined with ignorance of the addictability of the new drug resulted in many a soldier becoming chronically dependent.

Drugs have been taken by combatants since ancient days to enhance their courage and ferocity, or to reduce their fears.

Opium, alcohol, amphetamines, hashish, hallucinogenic mushrooms, cocaine, and other substances have been used by individuals in times of danger. Battles, rebellions, and wars have been fought over these mind-altering drugs.

This is a period of excessive use of every class of drugs. Their overuse is worldwide reflecting sweeping changes in life style, tumultuous times, drastic alterations in personal values and the attenuation of established belief systems.

Viewed in this context the development of a drug problem in South Vietnam becomes somewhat more understandable. However, special factors are operant there, and they will be mentioned.

First, I would like to quickly review the situation there.

Five years ago reports of the increasing use of marihuana began to appear. The material is readily available and is of a quality superior to that sold in this country.

Mexican marihuana which represents most of the consumed product here, averages about 1 percent THC (tetrahydrocannabinol, the active ingredient). Marihuana which grows wild in the United States may be 10 to 15 times weaker. On the other hand Vietnamese marihuana may contain 3 percent THC or more.

This accounts, in part, for the increased incidence of brief psychotic reactions reported from that area. Other reasons for such adverse effects include an insecure setting, and lack of a concerned person to protect the user should an untoward reaction begin.

The patterns of marihuana use resemble those in this country among comparable age groups. Some 30 to 60 percent report that they have tried marihuana. A quarter to a third of all users are regular smokers. Of these, most use intermittently, but some fall into the category of "potheads" with multiple use every day.

From our experience in the United States, it seems clear that the escalation notion that marihuana leads to heroin is not valid except for a specific sample of users.

These are the potheads who are also inclined to excessive alcohol usage, and to indulge in sedatives, stimulants, hallucinogens and narcotics, all of these being quite available in Vietnam.

They tend to be a more disturbed group when compared to nonusers or occasional users of marihuana. On psychological testing they score high on emotional instability and immaturity, impulsivity and they exhibit a lowered tolerance for frustration.

In the presence of a supply of heroin, and especially when members of their group are using, such individuals tend to become addicted.

In Vietnam for the past year or two, heroin supplies have been readily available, and a moral deterrent does not seem to exist in some units.

We hear surprisingly little of opium smoking in Vietnam despite its popularity. "Curing" marihuana by dipping the "joint" in opium is a mild form of the practice. This is the "O.J." or "opium joint."

Crude opium with a low morphine content is inexpensive and plentiful. It is this material that is smoked. Needless to say smoking opium is addicting although not as intensely so as injecting heroin.

We have all heard that about 15 to 20 percent of the troops in Southeast Asia are addicted to heroin. I would like to question these figures and inquire what their basis is.

The heroin addiction problem is surely serious, but it seems incredible that one in five are addicts.

Substantial error can result from casually surveying small samples. Talking to a few dozen soldiers can produce figures which should not be extrapolated to the entire Armed Forces without considerable reservation.

If the percentages were obtained on the basis of urine testing of a random sample, this does not mean that everybody who has a urine positive for morphine-heroin is excreted as morphine-is an addict. Large numbers of servicemen may be "joy popping," that is, using on a weekend, and not developing tolerance or withdrawal symptoms, therefore they are not addicted.

"Joy popping" is a hazardous pastime. Every addict that I have talked to believed that he could go on "joy popping" and not become a daily user. It just does not work that way.

If indeed 20 percent are addicted, why are more not being seen at the Veterans' Administration or other treatment centers?

From the figures I have, during the 3 months ending September 30, 1970, 459 patients were treated at all VA hospitals for opiate-connected problems.

Of these 264 were under the age of 35. Not all of these were Vietnam veterans.

I have further information that in the first 9 months of fiscal year 1972, somewhat over a thousand Vietnamese veterans were treated in VA hospitals for their heroin addiction.

This still remains a rather modest number.

A few were probably under treatment for addiction incurred either in the course of treatment for some painful illness or following discharge from the Armed Forces.

The VA is seeing increasing numbers of addicted Vietnam veterans, but the figures are much lower than expected in view of the 15 to 20 percent estimate.

From inquiries I have made at civilian narcotic treatment centers, only a few recently discharged veterans are being seen.

Where are they?

The answer, I suspect, is multiple. First, the 20 percent figure which has been so frequently mentioned in the media is too high. After all, about 500,000 men were returned from Southeast Asia in the past year. Where are the 75,000 to 100,000 addicts that should have come home? The actual number will turn out to be much less.

Second, not everyone who has used heroin is addicted to it. It requires regular use of heroin for a week or two before sudden discontinuance will produce withdrawal sickness.

Even the very good Southeast Asian heroin which is 20 times stronger than District of Columbia heroin requires repeated injections over a number of days.

Third, a number of servicemen must be going through withdrawal on their own or with the assistance of their private doctors.

Fourth, an unknown number have probably drifted into the domestic heroin scene. This last group is a particularly tragic one, and it must be kept as small as possible.

Our distressing lack of precise information makes effective planning for the rehabilitation of those involved precarious. Data on addiction are notoriously difficult to obtain, but surely better estimates should be available to us.

This leads to the first recommendation to be offered:

1. The Department of Defense should be asked to survey the narcotic addiction problem among American personnel in Southeast Asia. They should provide a report as soon as possible on the nature and extent of the problem.

Although heroin addiction in Vietnam may not be as widespread as the above estimates indicate, it remains a most serious situation worthy of your contnuing attention and concern.

To the personal tragedy of the heroin way of life with its mental and physical disorganization, must be added the familiar and social chaos which is an intrinsic part of being a “junkie.”

Every effort to avoid perpetuating the addiction on return to civil life is mandatory. Treatment must be available to every afflicted veteran who requests it. An outreach program should be instituted to draw those veterans who are not motivated at this time to stop using heroin into a treatment program.

I would like to briefly mention the treatment possibilities that are available with special reference to their use in young addicts who have been addicted for relatively short periods of time.

Gradually reducing the daily amount of the narcotic over a period of a week or two prevents most of the withdrawal symptoms.

This is called detoxification, and it is usually done by using methadone given by mouth.

It is a simple and rapid procedure, but from the civilian experience we know that it produces abstinence in only 5 to 10 percent of addicts. Nevertheless, it should be used, particularly in the young addict of brief duration because the results in this group may be better than among older, chronic "junkies."

Counseling and other supportive services will improve the results. The costs are low, and personnel are at hand to accomplish mass detoxification.

Maintaining the addict on methadone over a prolonged period of time produces a remission rate of 50 to 80 percent. Heroin hunger is diminished, and if heroin is injected the "high" is prevented while on maintenance therapy.

Such treatment does not interfere with schooling or working. For the large-scale treatment of large numbers of addicts, methadone maintenance has many advantages. The costs run about $1,000 to $2,000 per patient year depending on the ancillary services available. It is hoped that most recent addicts will not have to remain on maintenance treatment all their lives. After 6 to 12 months they may be able to come off methadone maintenance and remain abstinent. About 30,000 addicts are being treated in over 250 methadone maintenance programs at this time.

Self-help groups of the Synanon type are residential facilities run by ex-addicts. For highly motivated addicts who can endure the strenuous life-restructuring process, these groups offer abstinence from all drugs as their goal.

Some young addicts will be attracted to this method of dealing with their addiction.

This option ought to be available for those who want it.

Those who stay with the program do well, but up to 75 percent drop out during the first year.

Costs are greater than the programs already mentioned because it is a live-in situation. They are calculated at $10 a day, per person. The narcotic antagonists are providing assistance for only a few hundred addicts nationwide. Although they are an ideal solution to the treatment question, they are not a practical solution at this time. They provide a true blockade of heroin effects, but they are short acting, and more than half of the patients tend to drop out of treatment.

When long-acting forms become available, the narcotic antagonists will assume greater importance.

The results are not as favorable as methadone maintenance programs and the costs are comparable.

State and Federal commitment procedures are necessary for the addict who is not motivated to enter a voluntary program.

During the inpatient phase, efforts to bolster motivation are attempted.

After discharge from the hospital, he is treated as an outpatient in his community receiving necessary supportive services.

These programs are costly, and only a third of these difficult patients will have prolonged remissions.

The following treatment recommendations are made.

1. Methadone maintenance programs should be given support priority, but not to the exclusion of other treatment models.

2. Waiting lists must be abolished. The veteran addict seeking help should be considered an emergency, or he may drift into a lifetime of heroin use.

3. Treatment facilities in a community must be very closely coordinated. The problem is heroin addiction, not veteran or nonveteran heroin addiction. A VA unit will need referral capability to private facilities which it does not possess and which would be needlessly expensive to duplicate. All the methadone maintenance clinics in a city must exchange information, otherwise an addict can register in more than one at a time and divert the extra methadone onto the black market.

4. A single Federal agency should direct the entire civilian treatment, research, and prevention effort in drug abuse and narcotic addiction. We are fragmenting our efforts today. This agency should maintain the closest contacts with the military situation so that a unified approach to the drug abuse problem is developed.

5. The Armed Forces roles should be case finding and initial treatment, consisting of detoxification. For those wishing to remain in the military, long-range treatment can also be accomplished there. The Veterans' Administration hospitals could take over the long-range treatment of those leaving the service.

6. The search must go on for still better maintenance agents, prolonged acting narcotic antagonists, and innovative rehabilitative techniques.

7. The technology for the identification of the heroin user is at hand today. Thin layer chromatography of the urine is a reliable indicator of the presence of opiates and other drugs of abuse. This technology should be used for detection and to evaluate the course of rehabilitation.

8. Military drug addicts must be brought into prompt treatment for their own sake and for society's. It is most unwise to abandon them after they are identified. If we apply the public health model of treating contagious diseases to narcotic addiction, we might control the epidemic by trying to treat every victim and attempting to eradicate the causative agent.

Even more important than treatment in the definitive attack upon heroin addiction is prevention.

Primary prevention, or elimination of the heroin, is a matter for enforcement. It is my understanding that less than 10 percent of the heroin entering this country is confiscated.

What will happen to Southeast Asian heroin after the Americans have departed?

It would be unrealistic to assume that it will not follow the troops back home.

I have another concern involving domestic supplies of heroin. We have over 30,000 patients on methadone maintenance, and many other thousands who have successfully eliminated heroin from their lives.

By next year over a hundred thousand former addicts will be out of the heroin market.